Know Your Plan, Know Your Rights

Know Your Plan, Know Your Rights You must be an advocate for your care. You are the patient; you are the customer of the health insurance program in which you participate. In order to fully understand your health plan benefits and your rights under your health plan, become familiar with the following materials and resources.For additional information and resources, please visit our Understanding Insurance Coverage overview page.

“Know Your Plan, Know Your Rights” Topics

Summary Plan Description (SPD)

This document is provided by your employer and it, along with any separate benefit plan certificates or booklets for the health plan you are enrolled in, constitutes a SPD. It is designed to comply with the plan disclosure requirements set forth by the US Department of Labor under the Employee Retirement Income Security Act (ERISA) Act of 1974. These materials are used to understand the benefits provided by your employer.

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Certificate of Coverage

This is a Certificate provided by your health plan carrier, describing in detail the benefits covered under your plan. Typically, you want to know the specifics benefits before you enroll in the plan. To get access to the Certificate of Coverage ahead of time – call the health plan and ask if it is online – so you can view and print it. If it is not online, ask that they fax or mail you the Certificate, especially the sections pertaining to their infertility benefits.

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Web Resources

Many health plan carriers have plan details on their web sites. If you are not finding what you need, call the health plan and ask them to navigate you to the section on their site where specifics of the coverage is outlined.

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Appeals and Grievance Procedures

Health plans are required to communicate their appeals/grievance procedure to plan members, so plan members are clear about the process and the timing involved. If you have had a procedure denied, you will want to begin the appeals process with your health plan. If the claim is denied again, you can begin an appeal through the Office of Patient Protection (OPP), (see details on this site for the OPP).

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Your Employer’s Annual Open Enrollment Period

This is the time each year that employers allow employees to make changes to their health plan and coverage elections, in accordance with IRS guidelines. Usually, employees are given a period of two weeks or so, to decide if they want to move to another plan with their employer, to change coverage from family to individual or vice versa, or to enroll, or dis-enroll in a plan. It is important to know when this annual event occurs, and to do your research so you are aware of the specific infertility benefits under each of the plans you are exploring.

There are opportunities during the year to make changes to your employer health plan, if you have what is defined by the IRS as a “qualified event”. A qualified event is a major life event that triggers a need to make a change to your health plan election. An example is, marriage, divorce, birth, adoption, employment change for your spouse or yourself. If you have a qualified event, you may generally make a change to your plan election within 30 days of the event. Explore the options and details with your Benefits Office.

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Additional Insurance Resources from RNE